Western Union Payment Service 15/09/2019, 2)54 PM

Amount
Amount (in words) DO NOT WRITE IN THIS AREA

PayTo Operator
Agency
number

Company name
Date / / Time
Company code
Money Transfer Control Number

Country

Sender
Amount

First name(s) Charge

First Middle

Last name Tax

Paternal Maternal

Total amount
Street received

City Provence/Country Postal code

Identification
Telephone no. ( )( )
Account
Number Type Expiration

Reference Number
Number

If you would like payment directed to an individual or department, please specify here:
Agent's
signature
Name/Department

Customer's signature FSI 9034 (3/00)

THE TERMS AND CONDITIONS ON WHICH THE SERVICE IS PROVIDED ARE SET OUT ON THIS PAGE:
http://www.westernunion.com/info/tnc.asp
Copyright © 2000 WESTERN UNION FINANCIAL
SERVICE, INC.

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